Not upheld, recommendations

Summary

Mr C had an accident at work and was taken to Perth Royal Infirmary A&E, where his back and neck were examined and x-rayed. No bony injuries were identified and Mr C was discharged. He said that he told hospital staff that his arms and shoulders were extremely painful and heavy, but the only test that they carried out was that he was asked to squeeze the doctor's fingers. Mr C continued to have pain in his shoulders and arms and his GP referred him for an MRI scan (magnetic resonance imaging - used to diagnose health conditions affecting organs, tissue and bone). This showed that he had torn the rotator cuffs (the muscles around the shoulder joint) in both shoulders. Mr C continued to have shoulder problems, and complained that the A&E examination was inadequate and did not properly assess the extent of his injuries.

After taking independent advice from one of our medical advisers, we found that Mr C was examined in line with good practice. The range of movement in his arms and shoulders was checked and the finger squeezing test was carried out to check for nerve damage (which might have indicated a neck injury). The examination indicated that Mr C had soft tissue injuries, which would not show up on an x-ray. We did not uphold his complaint,as we found the decision to allow his injuries time to settle, with pain medication, to be appropriate. However, we noted a delay to Mr C's MRI scan and diagnosis when his pain did not resolve and made a recommendation related to this.

Recommendations

We recommended that the Board:

• share our decision with the staff involved in Mr C's treatment and diagnosis with a view to identifying any points of learning that may be used to improve the treatment of future patients; and
• remind their A&E staff of the importance of inviting patients to return to hospital or their GP should their symptoms persist, and of documenting the advice given to patients discharged from their care.

Summary

Mrs C complained about the medical care and treatment the medical practice gave to her late husband (Mr C). In particular, she was unhappy that he was not referred to hospital earlier.

During our investigation, we obtained independent advice from one of our medical advisers, who is a GP. We found that for the most part the treatment provided to Mr C was reasonable and appropriate. The adviser said that, although some GPs might have considered referring him to hospital earlier, the practice had acted within national guidelines and it was not unreasonable that Mr C was not referred earlier than he was. The medical records showed that the practice had been attentive and had managed Mr C's care as best they could.

We were, however, concerned that there was no evidence in the records that the practice had recognised and considered Mr and Mrs C's distress when deciding how best to progress his care. We were also concerned that there was no evidence to support the practice's position that Mr C was involved in the decision-making process. As a result we made a number of recommendations to further improve practice.

Recommendations

We recommended that the practice:

• provide us with evidence demonstrating how the practice involve the patient in the decision-making process; and
• consider this case to see if any further lessons can be learned, and bring the concerns raised by our investigation to the attention of the staff involved.

Summary

Ms C, who is an advocacy worker, complained on behalf of her client (Mr A) about a failure by staff at Monklands Hospital to properly assess and diagnose him after he attended the A&E department on two separate occasions. Mr A was initially diagnosed with a possible faint or seizure, with anxiety as the possible cause. He was discharged home and a referral made for him to attend a seizure clinic. Mr A then went to see his GP who referred him back to hospital, where he was admitted to intensive care and diagnosed with TB meningitis (an infection of the tissues covering the brain and spinal cord). Mr C had a very slow recovery and has been left with long term debility.

After taking independent advice from a medical adviser, we identified that there were shortcomings with the observations carried out on Mr A during both hospital visits. The board acknowledged that it was unacceptable that staff did not take Mr A's temperature during his first visit or repeat his observations when it was noted that his blood pressure and heart rate were raised. However, although we were critical of these omissions we did not consider that they were significant failings overall, nor were they likely to have led to an earlier diagnosis or different outcome. Our adviser said that TB meningitis is a very rare condition, and it was not unreasonable of the medical staff to attribute Mr A's symptoms to more common conditions such as anxiety and epilepsy. We concluded that the actions taken by staff were reasonable and in accordance with national guidelines. The board also showed us evidence that they have reviewed the observations procedure in the A&E department and made changes to ensure that the failings do not recur.

Recommendations

We recommended that the Board:

• apologise to Mr A for the failings in relation to his observations when he attended the hospital on two separate occasions.

Summary

Mrs C complained on behalf of her mother (Mrs A) that staff at Inverclyde Royal Hospital provided inadequate care and treatment to her. Mrs C also complained that communication from hospital staff was not good enough. Mrs A had started taking antibiotics for a urinary tract infection two days before admission, and was admitted to the hospital with increasing confusion. Mrs C was particularly concerned about a fall her mother had in hospital, as well as treatment for Mrs A’s confusion.

We received Mrs A’s medical records from the board, and took independent advice from our nursing adviser. There was no dispute that Mrs A fell; what was disputed was the reason for the fall. In this case, we could not resolve the dispute given the differing accounts of what happened, although that did not mean we believed one version over another. In Mrs C’s view, the fall was not addressed properly. The medical records showed that Mrs A was assessed after the fall, and no major injuries were found. Our adviser’s view, which we accepted, was that the care provided to Mrs A was reasonable in the circumstances. Based on the available evidence, we concluded that hospital staff provided adequate care and treatment to Mrs A.

The board said they should have phoned Mrs C earlier to tell her about Mrs A’s fall, and they apologised for this and reminded staff of the importance of keeping patients and relatives informed. We found evidence in the medical records that staff spoke to Mrs C regularly during Mrs A’s stay in hospital, and that they were aware Mrs C was unhappy. Our adviser observed that staff could have tried to offer more support to Mrs C when she was visibly upset. However, we decided that, on balance, communication from hospital staff to Mrs C was adequate in the circumstances.

Although we did not uphold Mrs C’s complaints, we made recommendations to address specific concerns raised by our adviser.

Recommendations

We recommended that the Board:

• reflect on this case, as part of ongoing improvements, to ensure that an appropriately detailed approach is taken to care planning to help manage delirium; and
• reflect on this case, as part of ongoing improvements, to ensure that staff provide support to relatives of patients with delirium.

Summary

Miss C was unhappy with the care and treatment she received during her pregnancy. She complained there was a failure to provide her with appropriate clinical treatment for an ovarian cyst (a fluid-filled sac) and to provide her with appropriate nursing care during her labour. When Miss C was about 18 weeks pregnant she had experienced severe abdominal pain. She had a consultation with an out-of-hours GP, who referred her to her own GP. She was later admitted to Forth Valley Royal Hospital with a suspected torsion (where the weight of the cyst causes the whole ovary to twist, cutting off the blood supply). A laparotomy (an open operation on the abdomen) was carried out. However, when the surgery was performed, no cyst was present (it appeared to have resolved on its own) and no other reason for Miss C’s pain was identified. Miss C was later prescribed antibiotics because the surgical wound was leaking. She considered the operation unnecessary and that it could have been avoided if she had been given an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) before surgery. She was also upset about the scar left by the operation, which she felt could have been avoided if she had been scanned or given a laparoscopy (keyhole surgery) instead of the laparotomy.

We took independent advice from a GP adviser, a midwifery adviser and an obstetrics adviser (a specialist in pregnancy, childbirth etc). The GP adviser said that it was reasonable for the out-of-hours GP to refer Miss C to her own GP. The obstetrics adviser said that, while performing the operation laparoscopically might have improved Miss C’s experience, the decisions to perform a laparotomy and to do so without a further ultrasound were reasonable. We found that the care and treatment provided to Miss C was reasonable in the circumstances known to the medical staff at the time.

In relation to Miss C’s complaint about nursing care during her labour, our midwifery adviser said that the midwifery care Miss C received during and following the birth of her baby was appropriate and in line with relevant guidance. Miss C was unhappy with the conditions in the room where she gave birth but, although we considered these to be less than ideal, we did not consider that they amounted to unreasonable care.

Although we did not uphold Miss C’s complaints we noted that the board intended to review the management of her care to allow any learning to be identified and ensure improvement and development if required, and so we made a relevant recommendation.

Recommendations

We recommended that the Board:

• provide us with evidence of the review of the management of Miss C's care carried out at their clinical review group meeting.

Summary

Mr C, who is a prisoner, complained that prison staff had decided to restrict his partner to closed visits (when the prisoner and his visitor are separated by a pane of glass). On some occasions, his partner was refused entry altogether. The prison confirmed that the restrictions on these visits were in place because of concerns about his partner's behaviour towards staff. They told us about the types of behaviours they had witnessed and provided supporting statements from staff. They also confirmed that they had reviewed the arrangements after three months, as they were required to do. We told Mr C that the prison were entitled to take action if they had concerns, and that we cannot question that decision unless there is evidence that it was not taken properly.

Mr C also complained that he was not invited to his complaint hearing about this, despite having said he wanted to attend. He said he did not know it had taken place until he received the decision. The prison told us that Mr C was invited to attend but failed to do so. They provided a copy of the attendance sheet recording his failure to attend. As we could not reconcile the conflicting accounts of what happened, we did not uphold this complaint. We noted, however, that the written note from the hearing did not mention that Mr C was not there. We considered that it would have been good practice for this to have been noted and made a recommendation.

Recommendations

We recommended that Scottish Prison Service:

• remind staff acting as internal complaints committee chairpersons that, as a matter of good practice, the written note of the hearing should make it clear when a prisoner has failed to attend.

Summary

Mr C had had a childhood illness that resulted in facial paralysis. Over the years, he had undergone a number of surgical procedures to improve his facial appearance. However, he complained he had been left with increased paralysis, loss of function and facial pain. He said that his appearance was worse and he had suffered nerve damage. He was at a loss to understand how this had happened and questioned the care and treatment he had been given. He complained to the board, who said that all the procedures undertaken were done with his informed consent and that his treatment was appropriate to his condition.

In investigating the complaint, we took independent advice from a specialist surgeon and a pain specialist, as well as carefully considering all the relevant information, including all the correspondence and Mr C's clinical records. Although we understood Mr C's concerns, the advice we received was that the treatment he had was appropriate and of a good standard, and the clinical notes confirmed that it was fully discussed with him in advance. When Mr C complained, his concerns and symptoms were appropriately and sympathetically dealt with. However, as the pain consultant said there were alternative methods of pain control that it might be helpful for Mr C to try, we made a recommendation about this.

Recommendations

We recommended that the board:

• give consideration to the provision of non-pharmacological means of pain control for Mr C.

Summary

Mrs C cared for her late husband (Mr C) at home with assistance from carers, district nurses, Mr C's GP and the board's palliative care (care provided solely to prevent or relieve suffering) team when necessary. On the day Mr C died, Mrs C had phoned the board's palliative care line as her husband was in severe pain. An out-of-hours (OOH) GP arrived within 47 minutes of her call to provide pain relief to Mr C, who died around an hour later. Mrs C complained about the length of time it took for the OOH GP to attend and administer the pain relief.

The palliative care line is part of the board's OOH service and it helps palliative care patients to get help without having to go through NHS 24. It is not an emergency service but the board aims to respond to priority calls within one hour. Mr C was visited within 47 minutes of Mrs C's phone call and, even although Mr C was in a lot of pain, we concluded that this was within a reasonable timescale. We noted that when a palliative care patient is nearing the end of their life, an anticipatory pack of medication is often provided to help with distressing symptoms, such as pain, nausea, agitation and breathlessness. This is, however, a decision for the primary care team involved in the patient's care, not the OOH service. Although we did not uphold the complaint, we made recommendations to address our concerns about this.

Recommendations

We recommended that the board:

• ensure that the relevant primary care team review whether anticipatory care planning was in place for Mr C in line with NHS Scotland Palliative Care Guidelines (March 2012) and, if any areas of improvement are identified, prepare an action plan for implementation.

Summary

Ms C complained that the university had not responded to her emails about feedback, as she said what she was receiving was not adequate. The university investigated her concerns but did not uphold her complaints.

Our investigation found evidence that the university had not responded directly to every email sent but had addressed the matters raised through other means. We found that the university had conducted their investigation reasonably and, although they should have responded to emails, they had addressed Ms C's concerns and did not rely on inaccurate information in responding. Although we did not uphold Ms C's complaint, we made a recommendation.

Recommendations

We recommended that the university:

• consider introducing a policy to enable staff to better manage communications with students and advise us of the outcome of their consideration.

Summary

Mr C, who is a prisoner, had an external work placement, but was suspended from this because the prison said he had breached the conditions of his temporary release licence. Mr C complained that the prison did not deal with or investigate this in line with their procedures. He also complained that the prison did not handle Risk Management Team (RMT) matters in line with their procedures, and did not adequately deal with his complaints about all these matters.

During our investigation we found that Mr C had signed to agree that he had read the licence conditions attached to his temporary release. The Scottish Prison Service (SPS) took the view that he had breached these conditions as his placement had closed early one day, but he had not contacted the prison when this happened. This was a discretionary decision that the SPS were entitled to take. We were also satisfied that the prison investigated the alleged breach of licence conditions in line with their normal process, and that it was correctly dealt with through the risk management process. Mr C spoke at the RMT meeting that considered the matter, and his account of what happened was noted in the minute of that meeting. We were also satisfied that the SPS dealt with his complaints in line with their process.

Although we did not uphold the complaints, we noted that Mr C said he was not given a copy of the relevant paperwork. The SPS said that he was, but were unable to provide evidence of it, so we made a recommendation about this.

Recommendations

We recommended that the SPS:

• take steps to ensure a prisoner confirms receipt when provided with a copy of an adverse circumstances report and any related paperwork.